Review

. 2024 Oct 18;19(1):33.

doi: 10.1186/s13017-024-00559-2.

Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper

Giacomo Sermonesi¹, Riccardo Bertelli¹, Fredric M Pieracci², Zsolt J Balogh³, Raul Coimbra⁴, Joseph M Galante⁵, Andreas Hecker⁶, Dieter Weber⁷, Zachary M Bauman⁸, Susan Kartiko⁹, Bhavik Patel¹⁰, SarahAnn S Whitbeck¹¹, Thomas W White¹², Kevin N Harrell¹³, Daniele Perrina¹, Alessia Rampini¹, Brian Tian¹⁴, Francesco Amico¹⁵, Solomon G Beka¹⁶, Luigi Bonavina¹⁷, Marco Ceresoli¹⁸, Lorenzo Cobianchi^{19

20}, Federico Coccolini²¹, Yunfeng Cui²², Francesca Dal Mas^{20

23}, Belinda De Simone²⁴, Isidoro Di Carlo²⁵, Salomone Di Saverio²⁶, Agron Dogjani²⁷, Andreas Fette²⁸, Gustavo P Fraga²⁹, Carlos Augusto Gomes³⁰, Jim S Khan³¹, Andrew W Kirkpatrick³², Vitor F Kruger²⁹, Ari Leppäniemi³³, Andrey Litvin³⁴, Andrea Mingoli³⁵, David Costa Navarro³⁶, Eliseo Passera³⁷, Michele Pisano³⁷, Mauro Podda³⁸, Emanuele Russo¹, Boris Sakakushev³⁹, Domenico Santonastaso¹, Massimo Sartelli⁴⁰, Vishal G Shelat⁴¹, Edward Tan⁴², Imtiaz Wani⁴³, Fikri M Abu-Zidan⁴⁴, Walter L Biffl⁴⁵, Ian Civil⁴⁶, Rifat Latifi⁴⁷, Ingo Marzi⁴⁸, Edoardo Picetti⁴⁹, Manos Pikoulis⁵⁰, Vanni Agnoletti¹, Francesca Bravi⁵¹, Carlo Vallicelli¹, Luca Ansaloni¹⁹, Ernest E Moore², Fausto Catena¹

Affiliations

¹ Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy.
² Department of Surgery, University of Colorado School of Medicine, Denver, CO, USA.
³ Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia.
⁴ Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System Medical Center, Moreno Valley, CA, USA.
⁵ Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA.
⁶ Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany.
⁷ Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia.
⁸ Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
⁹ Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
¹⁰ Division of Trauma, Gold Coast University Hospital, Southport, QLD, Australia.
¹¹ Chest Wall Injury Society, Salt Lake City, UT, USA.
¹² Intermountain Medical Center, Salt Lake City, UT, USA.
¹³ Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA.
¹⁴ Department of General Surgery, Singapore General Hospital, Singapore, Singapore.
¹⁵ Discipline of Surgery, School of Medicine and Public Health, Newcastle, NSW, Australia.
¹⁶ Ethiopian Air Force Hospital, Bishoftu, Oromia, Ethiopia. sologbeka@gmail.com.
¹⁷ Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy.
¹⁸ General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy.
¹⁹ Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
²⁰ Collegium Medicum, University of Social Sciences, Lodz, Poland.
²¹ Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy.
²² Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China.
²³ Department of Management, Ca' Foscari University of Venice, Venice, Italy.
²⁴ Department of Minimally Invasive Emergency and General Surgery, Infermi Hospital, Rimini, Italy.
²⁵ Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy.
²⁶ General Surgery Department Hospital of San Benedetto del Tronto, Marche Region, Italy.
²⁷ Department of General Surgery, University of Medicine of Tirana, Tirana, Albania.
²⁸ Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany.
²⁹ Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil.
³⁰ Faculdade de Medicina, SUPREMA, Hospital Universitario Terezinha de Jesus de Juiz de Fora, Juiz de Fora, MG, Brazil.
³¹ Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.
³² Departments of Surgery and Critical Care Medicine, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.
³³ Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
³⁴ Department of Surgical Diseases No. 3, University Clinic, Gomel State Medical University, Gomel, Belarus.
³⁵ Policlinico Umberto I University Hospital, Sapienza University of Rome, Rome, Italy.
³⁶ Colorectal Surgery Unit, Trauma Care Committee, Alicante General University Hospital, Alicante, Spain.
³⁷ Departments of Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy.
³⁸ Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy.
³⁹ General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria.
⁴⁰ Department of Surgery, Macerata Hospital, Macerata, Italy.
⁴¹ Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore.
⁴² Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands.
⁴³ Government Gousia Hospital, Srinagar, India.
⁴⁴ Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates.
⁴⁵ Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA.
⁴⁶ Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
⁴⁷ Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
⁴⁸ Department of Trauma Surgery and Orthopedics, University Hospital Goethe University Frankfurt, Frankfurt, Germany.
⁴⁹ Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy.
⁵⁰ 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece.
⁵¹ Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy.

PMID: 39425134
PMCID: PMC11487890
DOI: 10.1186/s13017-024-00559-2

Review

Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper

Giacomo Sermonesi et al. World J Emerg Surg. 2024.

. 2024 Oct 18;19(1):33.

doi: 10.1186/s13017-024-00559-2.

Authors

Affiliations

¹ Department of General and Emergency Surgery, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy.
² Department of Surgery, University of Colorado School of Medicine, Denver, CO, USA.
³ Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia.
⁴ Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System Medical Center, Moreno Valley, CA, USA.
⁵ Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA.
⁶ Emergency Medicine Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany.
⁷ Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia.
⁸ Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
⁹ Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
¹⁰ Division of Trauma, Gold Coast University Hospital, Southport, QLD, Australia.
¹¹ Chest Wall Injury Society, Salt Lake City, UT, USA.
¹² Intermountain Medical Center, Salt Lake City, UT, USA.
¹³ Department of Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA.
¹⁴ Department of General Surgery, Singapore General Hospital, Singapore, Singapore.
¹⁵ Discipline of Surgery, School of Medicine and Public Health, Newcastle, NSW, Australia.
¹⁶ Ethiopian Air Force Hospital, Bishoftu, Oromia, Ethiopia. sologbeka@gmail.com.
¹⁷ Department of Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy.
¹⁸ General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy.
¹⁹ Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
²⁰ Collegium Medicum, University of Social Sciences, Lodz, Poland.
²¹ Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy.
²² Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China.
²³ Department of Management, Ca' Foscari University of Venice, Venice, Italy.
²⁴ Department of Minimally Invasive Emergency and General Surgery, Infermi Hospital, Rimini, Italy.
²⁵ Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy.
²⁶ General Surgery Department Hospital of San Benedetto del Tronto, Marche Region, Italy.
²⁷ Department of General Surgery, University of Medicine of Tirana, Tirana, Albania.
²⁸ Pediatric Surgery, Children's Care Center, SRH Klinikum Suhl, Suhl, Thueringen, Germany.
²⁹ Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil.
³⁰ Faculdade de Medicina, SUPREMA, Hospital Universitario Terezinha de Jesus de Juiz de Fora, Juiz de Fora, MG, Brazil.
³¹ Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.
³² Departments of Surgery and Critical Care Medicine, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada.
³³ Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
³⁴ Department of Surgical Diseases No. 3, University Clinic, Gomel State Medical University, Gomel, Belarus.
³⁵ Policlinico Umberto I University Hospital, Sapienza University of Rome, Rome, Italy.
³⁶ Colorectal Surgery Unit, Trauma Care Committee, Alicante General University Hospital, Alicante, Spain.
³⁷ Departments of Surgery, ASST Papa Giovanni XXIII, Bergamo, Italy.
³⁸ Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy.
³⁹ General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria.
⁴⁰ Department of Surgery, Macerata Hospital, Macerata, Italy.
⁴¹ Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore.
⁴² Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands.
⁴³ Government Gousia Hospital, Srinagar, India.
⁴⁴ Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates.
⁴⁵ Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA.
⁴⁶ Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
⁴⁷ Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.
⁴⁸ Department of Trauma Surgery and Orthopedics, University Hospital Goethe University Frankfurt, Frankfurt, Germany.
⁴⁹ Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy.
⁵⁰ 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece.
⁵¹ Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy.

PMID: 39425134
PMCID: PMC11487890
DOI: 10.1186/s13017-024-00559-2

Erratum in

Correction: Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper.
Sermonesi G, Bertelli R, Pieracci FM, Balogh ZJ, Coimbra R, Galante JM, Hecker A, Weber D, Bauman ZM, Kartiko S, Patel B, Whitbeck SS, White TW, Harrell KN, Perrina D, Rampini A, Tian B, Amico F, Beka SG, Bonavina L, Ceresoli M, Cobianchi L, Coccolini F, Cui Y, Dal Mas F, De Simone B, Di Carlo I, Saverio SD, Dogjani A, Fette A, Fraga GP, Gomes CA, Khan JS, Kirkpatrick AW, Kruger VF, Leppäniemi A, Litvin A, Mingoli A, Navarro DC, Passera E, Pisano M, Podda M, Russo E, Sakakushev B, Santonastaso D, Sartelli M, Shelat VG, Tan E, Wani I, Abu-Zidan FM, Biffl WL, Civil I, Latifi R, Marzi I, Picetti E, Pikoulis M, Agnoletti V, Bravi F, Vallicelli C, Ansaloni L, Moore EE, Catena F. Sermonesi G, et al. World J Emerg Surg. 2025 Jan 29;20(1):8. doi: 10.1186/s13017-024-00568-1. World J Emerg Surg. 2025. PMID: 39881319 Free PMC article. No abstract available.

Abstract

Background: Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF.

Methods: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements.

Results: A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection.

Conclusion: This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

Keywords: Consensus; Flail chest; Guidelines; Minimally invasive plating osteosynthesis (MIPO); Multiple rib fractures; Operative reduction and internal fixation (ORIF); Rib fixation; Rib fractures; Surgical stabilization of rib fractures (SSRF); Thoracic/chest trauma injury; Video-assisted thoracoscopy surgery (VATS).

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Conflict of interest statement

The authors declare no competing interests.

Figures

**Fig. 1**
Shows PRISMA flow chart of Review paper

See this image and copyright information in PMC

References

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Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper

Affiliations

Surgical stabilization of rib fractures (SSRF): the WSES and CWIS position paper

Authors

Affiliations

Erratum in

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical